Citation Nr: 18156045 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 18-23 032A DATE: December 6, 2018 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1958 to November 1960. This matter is on appeal from an April 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). Following a review of the Veteran’s claims file, the Board finds that further development is required prior to the adjudication of the claim on appeal. The Veteran contends that he has PTSD as a result of his service. He specifically reported that he was on a helicopter to Cuba when it was diverted. He feared that because he was on machine gun duty he would be targeted by the enemy. The Veteran also reported a stressor of being stationed at Fort Lewis in Washington state when a friend of his was killed in a motor vehicle accident when he was run over by a military truck while asleep on the ground in an unassigned area. The Board notes that the RO attempted to verify the Veteran’s claimed stressors by contacting the Defense Personnel Records Information Retrieval System (DPRIS) in December 2016. The RO received a response from the DPRIS indicating that it was unable to locate information regarding the stressor incident. In a May 2016 correspondence, a private physician noted that the Veteran reported having experienced nightmares and recurring thoughts about a friend of his who was killed within his troop. When his sister was treated for cancer in 2014, the Veteran began to have increased anxiety and PTSD symptoms as well as increased flashbacks to the traumatic incident where a soldier was killed by a heavy duty vehicle. The physician noted that the Veteran’s symptoms clearly demonstrated a level of PTSD that endured for over 50 years. The private physician provided a diagnosis of PTSD that varied in severity due to life stressors. In an August 2016 correspondence, the private physician (a psychologist), noted that the Veteran had experienced a traumatic event while in the military service and as a result of this event he had been experiencing crying spells and depressive symptoms. The Veteran reported that his PTSD symptoms began when a young soldier he knew was run over and killed by a military vehicle in the dark. On a March 2017 Disability Benefits Questionnaire (DBQ) for PTSD, a private psychologist noted that the Veteran had a confirmed diagnosis of PTSD. The psychologist opined that the Veteran’s PTSD was at least as likely as not incurred in or caused by fear based mental illness that occurred during his service. The psychologist noted that the Veteran’s PTSD symptoms began to occur while serving in the military and continued for many years subsequently with a high degree of frequency and intensity. The proximity of his symptoms developing and his military service support the likelihood that his PTSD was due to his in-service stressors. The Board notes that while the May 2016 and August 2016 correspondences found that the Veteran had PTSD which were related to a traumatic event during his military service, these opinions both related the Veteran’s PTSD to an unverified stressor. As noted above, a December 2016 correspondence from DPRIS specifically indicated that it was unable to locate information regarding the Veteran’s claimed stressor incident. As noted above, a private psychologist in a March 2017 DBQ for PTSD also opined that the Veteran’s PTSD was at least as likely as not incurred in or caused by fear based mental illness that occurred during his service as the Veteran’s PTSD symptoms began to occur while serving in the military and continued for many years subsequently with a high degree of frequency and intensity. However, the Board notes the psychologist’s rationale and factual basis for the nexus opinion is unclear. Notably, while the private psychologist found that the proximity of the Veteran’s symptoms developing and his military service supported the likelihood that his PTSD was due to his in-service stressors, the Board notes that the Veteran’s service treatment records are negative for in-service psychiatric symptoms related to reported in-service stressors. As a result, the Board finds that further development is needed so that a medical professional can review the entire medical record, consider a complete history, and provide informed opinions as to the relationship between any current acquired psychiatric disability, to include PTSD, and service. The matter is REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disability on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of any currently present acquired psychiatric disorder to include PTSD. The examiner should determine the nature, extent of severity, and etiology of any psychiatric disorder(s) which may have been present at any time during the pendency of this appeal, to include PTSD. The examiner should provide a diagnosis for any psychiatric disorder that existed during the pendency of this claim. Following review of the claims file, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such psychiatric disorder, to include PTSD if diagnosed, is related to any incident of the Veteran’s active duty service, to include a fear of hostile military or terrorist activity. All opinions expressed by the examiner must be accompanied by a complete rationale. Adequate reasons and bases for any opinion rendered must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 3. After completion of the above and any additional development deemed necessary, the issue on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James A. DeFrank, Counsel